Just when Americans thought the Obamacare repeal effort was dead and buried, President Donald Trump has exhumed it. The president says he wants a deal on health care even as he vowed Friday to unveil a massive tax cut for Americans — another enormously complicated mission. The White House is pushing for a vote on a new Obamacare replacement bill in the coming days.

The trouble is, Trump hasn't publicly demonstrated an ability to add or subtract provisions, or assemble a bipartisan coalition, to make a good deal happen.

The last bill, promoted by House Speaker Paul Ryan, was tanked by conservative members of the Freedom Caucus. Democrats who opposed that legislation didn't have to lift a finger.

Now, however, Trump says he has leverage to bring Democrats on board and help craft a solution. At issue is billions in subsidy payments to insurance companies that help cover medical costs for millions of low-income Americans. Trump says he may withhold those payments to insurers, which could hasten the collapse of Obamacare insurance markets in many states.

"Obamacare is dead next month if it doesn't get that money," Trump told The Wall Street Journal. "I haven't made my viewpoint clear yet. I don't want people to get hurt. ... What I think should happen and will happen is the Democrats will start calling me and negotiating."

This could be a presidential bluff or ... an opportunity. We've urged Republicans and Democrats to negotiate a bipartisan Obamacare replacement that will withstand public scrutiny the way the original law, passed with only Democratic votes, never has. We think there is room in this scrum for movement toward that goal. If Trump is ready and willing to include Democrats in his negotiations, they should hear him out.

Our advice to Trump and the GOP:

•Don't sabotage already-shaky markets by withholding from insurers the subsidy payments that help make coverage affordable for low-income Americans. A sweeping coalition of national medical groups, insurers, hospitals, the U.S. Chamber of Commerce and the Bipartisan Policy Center urge Trump to maintain the subsidies. Scrapping them could force insurers to raise rates for everyone and endanger coverage for millions of people. If that happens, Trump won't be able to blame Democrats. He and his fellow Republicans will wear the jacket. Conventional wisdom is that no Democrat will get near a Trump/GOP replacement for Obamacare. But Trump may be able to entice Dems who know Obamacare risks collapse; there's only one insurance carrier in nearly a third of U.S. counties and more insurers are jumping ship. Democrats who say they want Americans covered may have to show up or shut up.

•Don't weaken popular Obamacare provisions. Since the defeat of the Ryan-led bill, Republicans have been tweaking it to attract more conservatives from the Freedom Caucus. But some of the proposals floated reportedly could undercut the law's popular provision that insurers not be allowed to deny coverage for people with pre-existing conditions. Diluting or scrapping that provision could be a huge step backward, to a time when insurers cherry-picked customers and many people with serious illnesses couldn't gain or afford coverage. Some moderate Republicans wouldn't vote for such a bill. That said, there are ways to create special risk pools or other means to cover these Americans without crushing insurers. More imagination, please.

•Take another look at the proposal for an Obamacare replacement from a group of Republican senators led by Bill Cassidy of Louisiana and Susan Collins of Maine. Their Patient Freedom Act would give states flexibility to experiment, to learn the best way to help citizens buy the coverage they need and can afford. Under the proposal, states could keep Obamacare if they choose. Or they could design their own programs while receiving a similar amount of federal money. States could decide if they will maintain the current system of insurance exchanges. Or people could receive tax credits to subsidize premiums in new state-run marketplaces. States also could enroll people — such as young people who've rejected Obamacare's increasingly expensive (and increasingly high-deductible) coverage — in health plans that provide basic insurance against catastrophic medical expenses.

Like any good dealmaker, Trump surely hasn't divulged all his negotiating points. Nor will he take no for an answer if he thinks he can get to yes. He can, but only with Democrats' help, and only by blunting the self-centered Freedom Caucus.

A version of this article appeared in print on April 23, 2017, in the News section of the Chicago Tribune with the headline "Trump's Obamacare gambit - As the program risks collapse, Democrats who say they want Americans covered may have to show up or shut up." —
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